Gastroenterology specialty transcription challenges, technology and use of a specialist

Gastroenterology Specialty Transcription - Challenges, Technology and Use of a Specialist

Gastroenterology is a medical specialty concerned with the digestive system and its disorders. The major challenge gastroenterologists have to face is the lack of time for opportune and accurate patient documentation. Wasting time on documentation can limit the time for patient consultation and diagnosis, which can inversely affect patient care and satisfaction. Apart from this, incomplete or inaccurate documentation can also result in claim denials or delays.

Documentation Challenges Let us take for example a patient presenting with symptoms of belching. You will have to diagnose whether it is a gastric belch (normal physiologic activity) or a supragastric belch, which is typically a behavioral problem. You will have to review and document the patient history that would reveal the patient’s behavior pattern while sleeping and when distracted. Since supragastric belching is typically a behavioral problem, the belching should stop when sleeping or distracted. Once the diagnosis is made, you have to document that accurately.

Then comes the condition management part - Since belching tends to be worsened by stress, you will have to identify other behavioral components or psychological components that need to be considered. Neurocognitive symptoms that reveal underlying psychiatric disturbances can be managed with pharmacologic agents. In such cases, you have to refer the patient to a psychiatrist for counseling, neuropsychiatric evaluation or cognitive-behavioral therapy. There may be cases when the intervention of a speech pathologist may also be necessary. Sometimes hypnotherapy may prove to be useful.

All the above details have to be clearly recorded to ensure appropriate patient care and follow-up support. Many gastroenterologists would agree that it is easier to dictate patient data than enter it into an electronic record system.

Clinical components of a medical examination include information such as the following, which have to be accurately documented.           

Vital signs such as the patient’s temperature, pulse, respiratory rate and blood pressure Chief complaint Progress notes that show the care provided, and medical facts and inferences relevant to diagnosis and treatment Patient’s past medical history Family and social history Allergies Medication list History of present illness Review of systems (ROS) Diagnosis and assessment Plan and treatment

Whether in a traditional paper-based office or an advanced medical office with an EHR system in place, providers will have to document patient encounters. EHRs allow physicians to enter data by typing in free text, responding to templates that contain commonly used clinical terms, and symptoms, or by using voice recognition software. For a busy gastroenterologist, finding the time for documentation is a major challenge. This may ultimately result in cutting down the number of patients,

which is bound to have an impact on the practice revenue and also lead to patient dissatisfaction.

Is Speech Recognition Software a Reliable Solution?

According to a research report, use of voice recognition in radiology practices has increased the number of error reports quite significantly. This can happen in a gastroenterology practice as well. This usually happens in noisy places with a high workload and the reports are prepared by providers whose first language is not English. The software is not good at recognizing voices with heavy accents and cannot deal with disorganized dictation, poor grammar, and missing or overused punctuation. Increased cost for implementation is another factor that makes human transcription superior over voice recognition technology.

Even with a speech recognition system that is claimed to be reliable, human editing of the transcripts is necessary. Medical transcription companies in the present era offer the service of their medical transcriptionists who are medical language specialists (MLSs) for physicians looking to streamline their workflow.

How a Medical Transcription Company Can Help Meet the Challenge Assigning the task of medical documentation to a medical transcription company will be helpful for gastroenterologists to have quality documentation services, within specified time limits. Their team of experienced professionals provides specialtyspecific transcription services, in this case, gastroenterology.

Professionals handling gastroenterology transcription will be well versed in medical terminology, conditions and procedures specific to gastroenterology. You can continue dictating as you are used to and the medical transcription company will provide transcripts of reports such as the following.        

Biopsy of liver reports Colonoscopic reports Consultation notes Endoscopic examination reports History and physical examinations Laboratory test reports Nasogastric and intestinal tube reports Sigmoidoscopy reports

EMR/EHR Transcription Service This is the era of electronic health records and therefore reliable medical transcription companies have risen to the occasion, providing efficient EHR/EMR transcription service. They offer different EMR and EHR transcription interface solutions to ensure a smooth transcription process and outstanding quality.

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Transfer via network: the transcribed reports are delivered directly into the relevant folders in the provider’s network based on the provider’s scheduling preferences.

HL7 interface system: patient information is easily and efficiently captured from the provider’s HIS/CIS/RIS systems and the transcribed reports are returned to these systems within the required turnaround time.

Direct connection tool: using a VPN or other direct connection tools, real-time transcription is provided into the provider’s system.

Gastroenterology Transcription Outsourcing Benefits Cost-effectiveness is one of the major advantages of outsourcing medical transcription. The services are provided at affordable cost, and gastroenterologists can save 30-40% of the overall cost.

Confidentiality and security of gastroenterology medical reports are important for ensuring privacy of patient information. Service providers conscious of HIPAA compliance ensure utmost security and confidentiality for your medical documents.

Moreover, doctors can rely on convenient dictation option such as digital recorders and toll-free numbers, for accessing their service.

Accuracy: - Quality services are ensured by skilled professionals, with adequate knowledge in gastroenterology terms and procedures.

Timeliness: - Professional transcription companies follow strict time schedules and produce the transcribed reports in quick turnaround time.

Efficiency: - As the team of medical transcriptionists is specialized with terminologies and procedures in gastroenterology, they can deliver efficient services, both in terms of quality and quantity.

There is no doubt that reliable gastroenterology transcription including EMR/EHR transcription service will help gastroenterologists benefit from improved patient documentation. Though the electronic health record system is quickly changing the working pattern in medical practices, patients are still being seen, medical charts are being created and medical transcriptionists or medical language specialists still have an important role to play when it comes to documentation and quality assurance of the medical records. Medical transcriptionists are also indispensable in practices using voice recognition software. There they can take up the role of editors, clinical data specialists, data quality managers, and decision support specialists to ensure error-free medical records.

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